Effect of acute tryptophan depletion on noradrenaline and dopamine in the rat brain

In human subjects, the acute tryptophan (TRP) depletion (ATD) paradigm has been shown to have effects on mood and cognition. It is assumed that these effects are mediated through the serotonin system. In this study, we have examined the effects of ATD on the central concentrations of the monoamine transmitters, noradrenaline (NA) and dopamine (DA) as well as on serotonin (5-HT). Effects on NA and DA could also affect mood and cognition. Following oral administration of TRP-containing (TRP+) and TRP-free (TRP-) amino acid mixtures, neurotransmitter concentrations and free plasma TRP concentrations were determined by High Performance Liquid Chromatography (HPLC) with electrochemical detection. Free plasma TRP was significantly and substantially reduced (79%) in rats given a TRP- amino acid mixture when compared with those given a TRP+ mixture. ATD also significantly decreased 5-HT and 5-hydroxyindolacetic acid in the frontal cortex, remaining cortex and hippocampus, but did not significantly reduce these in the striatum. Furthermore, ATD did not significantly alter the concentration of NA and DA in any brain region examined. This study demonstrates that the administration of a TRP- amino acid mixture in rats can reduce free plasma TRP to levels comparable to those reported in human studies. These results indicate that behavioural and cognitive changes produced by ATD in preclinical or clinical studies are likely to be due to specific effects on the serotonergic system.

Use of intralesional oestradiol concentration to identify a functional pulmonary metastasis of canine sertoli cell tumour

A seven-year-old, 31 kg male neutered Labrador was investigated for signs of feminisation syndrome and prostatic disease four years after castration and removal of a testicular sertoli cell tumour (SCT). Investigations revealed an elevated serum oestradiol-17beta concentration, a pulmonary mass containing fluid high in oestradiol-17beta and cystic changes in the prostate gland. The pulmonary mass was surgically excised and histologically confirmed to be a SCT metastasis. To the authors' knowledge, this is the first reported case of a proven functional extranodal SCT metastasis and the first to be diagnosed by oestradiol-17beta measurement of intralesional fluid.

The determinants of change in patella cartilage volume--a cohort study of healthy middle-aged women

OBJECTIVES

Although cartilage loss occurs with advancing age and is a hallmark of OA, the factors that affect cartilage change are not well established. The aim of this study was to explore the determinants of change in patella cartilage volume over 2 yrs among healthy middle-aged women with no clinical knee OA.

METHODS

One hundred and forty-eight women with no clinical knee OA were recruited from a previous population-based cross-sectional study of healthy women aged 40-67 yrs. MRI was performed at baseline and at 2 yrs, to assess patella cartilage and bone volume. Self-reported exercise was assessed by questionnaire.

RESULTS

Annual loss of patella cartilage volume was 1.6% (95% CI 1.2, 1.9). Age was positively associated with patella cartilage volume loss after adjustment for confounders (P = 0.05). For every 1 mm(3) increase in patella bone volume at baseline, annual cartilage loss was reduced by 8.05 mm(3) (95% CI 12.91, 3.19; P < 0.001). Fortnightly participation in exercise promoting an increased heart and respiratory rate for at least 20 min also tended to be associated with a reduced rate of patella cartilage volume loss (P = 0.09).

CONCLUSION

Among middle-aged women with no clinical knee OA, advancing age expedites the rate of patella cartilage volume loss, while increased patella bone volume and exercise participation tends to be associated with a reduction in the rate of patella cartilage volume loss. Interventions targeting modifiable factors, such as physical activity, warrant further investigation as they may help to prevent patellofemoral OA.

The contribution of late termination of pregnancy to stillbirth rates in Northern England, 1994-2005

The impact of late terminations (> or = 24 weeks) on the overall stillbirth rate was determined for the 12-year period from 1994 to 2005 using data collected by the Regional Maternity Survey Office in the north of England. It is a legal requirement to register late terminations, and this may lead to an overestimation of the true stillbirth rate. In our region, terminations resulting in stillbirth increased the registered stillbirth rate by nearly 10%. The impact remained stable for the period 1998-2005. This suggests that the failure of the national (and regional) stillbirth rate to decline in recent years is not due to an increase in late terminations.

Estimating the magnitude of trastuzumab effects within patient subgroups in the HERA trial

BACKGROUND

Trastuzumab (Herceptin(R)) improves disease-free survival (DFS) and overall survival for patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer. We aimed to assess the magnitude of its clinical benefit for subpopulations defined by nodal and steroid hormone receptor status using data from the Herceptin Adjuvant (HERA) study.

PATIENTS AND METHODS

HERA is an international multicenter randomized trial comparing 1 or 2 years of trastuzumab treatment with observation after standard chemotherapy in women with HER2-positive breast cancer. In total, 1703 women randomized to 1-year trastuzumab and 1698 women randomized to observation were included in these analyses. Median follow-up was 23.5 months. The primary endpoint was DFS.

RESULTS

The overall hazard ratio (HR) for trastuzumab versus observation was 0.64 [95% confidence interval (CI) 0.54-0.76; P < 0.0001], ranging from 0.46 to 0.82 for subgroups. Estimated improvement in 3-year DFS in subgroups ranged from +11.3% to +0.6%. Patients with the best prognosis (those with node-negative disease and tumors 1.1-2.0 cm) had benefit similar to the overall cohort (HR 0.53, 95% CI 0.26-1.07; 3-year DFS improvement +4.6%, 95% CI -4.0% to 13.2%).

CONCLUSIONS

Adjuvant trastuzumab therapy reduces the risk of relapse similarly across subgroups defined by nodal status and steroid hormone receptor status, even those at relatively low risk for relapse.

An open-label, multicenter study of outpatient capecitabine monotherapy in 631 patients with pretreated advanced breast cancer

BACKGROUND

Phase II/III trials have shown that capecitabine is an active, well-tolerated therapy for metastatic breast cancer (MBC). We report clinical findings from an expanded access program enabling patients ineligible for investigative trials to receive capecitabine before its approval and availability.

METHODS

Patients pretreated with at least two chemotherapy regimens, including a taxane, for MBC received oral capecitabine until disease progression or unacceptable toxicity.

RESULTS

Six hundred and thirty-one patients received capecitabine (mean duration 3.8 months, range 0.1-24.7 months). The most common treatment-related grade 3/4 toxicities were diarrhea (9%) and hand-foot syndrome (8%). Grade 3/4 alopecia was absent and grade 3/4 myelosuppression was rare. Dose was modified in 172 patients (27%). Objective response rate in 349 evaluable patients was 35%. Median time to progression (n = 604) was 6.6 months (95% confidence interval, CI, 5.6-7.6) and median overall survival (n = 569) was 10.0 months (95% CI, 8.5-15.3).

CONCLUSIONS

Our findings in a cohort of patients with pretreated progressive breast cancer confirm the high efficacy and tolerability of outpatient capecitabine.

Microtearing instabilities and electron transport in the NSTX spherical tokamak

We report a successful quantitative account of the experimentally determined electron thermal conductivity chi(e) in a beam-heated H mode plasma by the magnetic fluctuations from microtearing instabilities. The calculated chi(e) based on existing nonlinear theory agrees with the result from transport analysis of the experimental data. Without using any adjustable parameter, the good agreement spans the entire region where there is a steep electron temperature gradient to drive the instability.

A sheet-bulging machine with closed-loop control

The design and performance of a machine for testing sheet material in the plastic range is described. The material is stressed in uniform biaxial tension by means of the hydrostatic bulge test. Test variables are measured by electrical transducers and an analogue unit is employed to permit autographic recording of the diagram relating true stress and natural strain. Closed-loop control of the rate of straining is achieved with an electro-hydraulic actuator; the feedback signal is derived from the analogue unit and the test can be controlled on the basis of a computed parameter such as true stress or natural strain.

A phase II study of paclitaxel and vinorelbine (Pac-Vin) in hormone-refractory metastatic prostate cancer (HRPC): A final update

15505

Background: Phase 2 trials of Paclitaxel + corticosteroid or Vinorelbine + corticosteroid have shown 20–40% PSA responses. Preclinical models have shown synergy between Paclitaxel and Vinorelbine. A phase I trial showed this to be a tolerable combination. Methods: The aim of this study was to determine the efficacy and safety of Paclitaxel and Vinorelbine. 30 castrate pts with progressive, metastatic prostate cancer were enrolled. Previous radiotherapy, strontium therapy, 1 line of chemotherapy, and concurrent bisphosphonate therapy were allowed. Pts were treated with Paclitaxel 40 mg/m2 (1 hr), and Vinorelbine 20 mg/m2 iv on day-1 & day- 8 of a 21-day cycle. All pts received standard premedication for Paclitaxel including dexamethasone. Results: Baseline pt characteristics were: median ECOG PS of 1 (range 0–2), median age 70.5, mean PSA 413 ng/mL, mean Hb 11.9 g/dL. For 10 pts with measureable disease the partial response rate was 20%, with 70% of pts achieving stable disease (SD). Of 30 assessable pts, 20% had a 50% or greater decline in PSA, and 63% SD, maintained for at least 4 weeks. Median overall survival was 9.7 months. Median progression free survival was 5.1 months. All pts completed quality of life (QOL) questionnaires. Patient’s pain, fatigue, appetite, constipation, and mood improved after 3 cycles of therapy, however, statistical significance was not reached. Grade 3&4 toxicities were: neutropenia 8%, febrile neutropenia 4%, infection 2%, anemia 3%, lethargy 1%, and somnolescence 1%. 1 pt died as a result of neutropenic sepsis. Conclusions: In this poor prognostic cohort of pts (where 17% of pts had received 1 prior chemotherapy regimen) the combination of Paclitaxel and Vinorelbine is a tolerable regimen, which has demonstrated a 20% PSA response. The majority of pts achieved PSA stability. There was similar rate of objective response to this regimen and importantly it stabilized disease in a majority of pts. Furthermore, QOL parameters such as pain were improved. This regimen is one that requires further testing in a poor prognostic cohort of HRPC pts.

No significant financial relationships to disclose.

A phase I/II study of an antitumor vaccination using α (1,3) galactosyltransferase expressing allogeneic tumor cells in pancreatic cancer

13512

Background: Prognosis of pancreatic cancer remains poor despite surgical resection. In a phase I trial, we examined the safety and feasibility of antitumor vaccination in Pts with surgically resected pancreatic cancer with two irradiated genetically altered human pancreatic cancer cell lines engineered to express xenotransplantation antigens by retroviral transfer of the murine a(1,3) galactosyltrasferase gene {HyperAcute Pancreatic Cancer Vaccine (HAPa)}. Methods: Pts had undergone complete surgical resection for stage IA to IIB pancreatic adenocarcinoma, ECOG PS≤2, no immunosuppressive drug use and an adequate organ function were eligible. Various adjuvant treatments were allowed prior to the start of HAPa according to the institutional preferences (5FU/radiation, cisplatin/gemicitabine followed by 5FU/radiation, 5FU/radiation followed by gemicitabine or gemicitabine/capecitabine/bevasizumab/radiation). Six Pts were scheduled to receive 12 every two week-intradermal injections (initial priming dose followed by 11 boost doses). The first cohort (Pts 1–3) was to receive at lower doses (2 × 108 cells priming and 1 x 108 cells boost). The second cohort (Pts 4–6) was to receive at higher doses (5 x 10^8 cells priming and 3 x 10^8 cells boost). Toxicity was assessed using the CTC v3.0. Results: To date, 6 Pts, 3 males, 3 females, median age 59 (range 50–66) were treated. Two Pts completed all 12 injections. Others received 9, 6, 6 and 4 injections, respectively. To date no serious adverse events can be attributed to the vaccine. Adverse events (≤CTC grade 2) attributable to the vaccine include injection site pain/discomfort and local skin reaction in all Pts. Other adverse events (≤grade 2) include hyperkalemia, fever and increased LDH levels in one Pt. One Pt with non-malignant hepatic lesions at the time of initial surgery was removed from the study after confirmation of metastatic disease in the liver. At this point the median 6.5 (range 9–4) months in the study all remaining (5/6) patients have no evidence of recurrent disease. Conclusions: Preliminary data indicate that antitumor vaccination with genetically altered allogeneic human pancreatic cancer cells expressing a(1, 3) galactosyltrasferase is safe and feasible

[Table: see text]

Pharmacoeconomic analysis of a combination of capecitabine (X) with docetaxel (D) and trastuzumab (H) first-line in HER2- positive advanced or metastatic breast cancer

17036

Background: A recently published (Wardley et al ESMO 2006) randomized phase II trial (CHAT) compared XDH with DH. The primary endpoint, overall response rate, was similar with XDH (71%) and DH (73%), while XDH showed superior time to progression (TTP) (hazard ratio [HR] 0.70, p=0.045, median 18.2 vs 13.8 months, respectively) and a trend toward superior progression-free survival (HR 0.72, p=0.06, median 14.8 vs 12.8 months, respectively). Overall survival data are immature. This analysis evaluates potential pharmacoeconomic impacts of adding X to DH. Methods: Direct medical costs during the study were estimated from the Italian health system perspective. Actual doses of both regimens were modeled from trial data. Grade 3/4 adverse events (AEs) and related medications were analyzed to estimate costs of treating major AEs. Other costs relating to laboratory tests and drug administration were assumed to be the same in both arms. Results: Total direct medical costs were slightly lower for XDH: €15250 vs €15570 for DH. As expected, the main cost drivers were drug costs: €14,370 vs €14,690, respectively. XDH and DH safety profiles were different: XDH resulted in more grade 3/4 non-hematologic AEs than DH (total: 77% vs 68%; hand-foot syndrome: 16% vs <1%; diarrhea: 11% vs 4%, respectively), but less grade 3/4 neutropenia (54% vs 77%), complicated neutropenia (20% vs 24%) and febrile neutropenia (14% vs 23%). The estimated mean AE costs per patient were similar in both arms. Conclusion: With the convenience of oral therapy, adding X to DH does not increase the number and duration of infusion visits or increase costs. For patients, physicians and payers, XDH is a good alternative for the treatment of advanced/metastatic breast cancer.

[Table: see text]

Assessing the risk of bone fracture among postmenopausal women who are receiving adjuvant hormonal therapy for breast cancer

OBJECTIVE

To understand better the true impact of widespread adoption of adjuvant aromatase inhibitor (AI) therapy on postmenopausal breast cancer patients' risk of bone fracture.

METHODS

Data from three different studies were used to estimate the relative risk of bone fracture for each of the following groups of women (i.e., versus a control group of healthy postmenopausal women): (a) healthy postmenopausal women receiving tamoxifen; (b) postmenopausal women who had received treatment for early breast cancer; (c) postmenopausal breast cancer patients on adjuvant tamoxifen therapy; (d) postmenopausal breast cancer patients on adjuvant anastrozole therapy. The results of these analyses were then used to estimate the likely incidence of clinical fracture among such populations in 'real-life' clinical practice.

RESULTS

Breast cancer survivors were calculated to be at increased risk of clinical bone fracture (i.e., RR 1.15 vs. control group over 5 years). Breast cancer patients initiated on adjuvant anastrozole were also calculated to be at increased risk of bone fracture (RR = 1.36 vs. control group over 5 years), while the calculated risk of fracture among tamoxifen-treated breast cancer patients was similar to that observed in the control population (RR = 0.91).

CONCLUSION

Breast cancer patients are at increased risk of clinical bone fracture (compared with the general postmenopausal population) and adjuvant anastrozole therapy slightly adds to this risk. Importantly, however, the absolute risk of bone fracture appears to remain low in each of the evaluated patient populations, suggesting that fear of fracture should not prevent the initiation of adjuvant aromatase inhibitor therapy.

Size matters: gastric pouch size correlates with weight loss after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Over the past 20 years, there has been an ongoing discussion about the importance of gastric pouch size as a key factor influencing weight loss after bariatric surgery. This analysis aimed to determine the relationship between initial gastric pouch size and excess weight loss (EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Between August 2002 and March 2005, 320 LRYGB were performed at Yale New Haven Hospital. The patients' demographics were entered into a longitudinal, prospective database. Upper gastrointestinal series were routinely performed on postoperative day 1. Pouch size was measured as area (cm2) on an anteroposterior radiograph at maximum pouch distention. Linear regression analysis was performed to determine the association between pouch size and weight loss at 6 and 12 months postoperatively. Adjustments were made for age, gender, and preoperative body mass index (BMI).

RESULTS

The mean age of the patients was 41.2 years. Of the 320 study patients, 261 were women (81.6%) and 59 were men (18.4%). The mean preoperative BMI was 51.1 kg/m2; the mean 6-month EWL was 50.5%; the mean 12-month EWL was 62.5%; and the mean pouch size was 63.9 cm2. A statistically significant, negative correlation between pouch size and EWL was found at 6 months (beta = -0.241; p < 0.01) and at 12 months (beta = -0.302; p < 0.02). The findings show that male gender (beta = 0.147; p < 0.04) and preoperative BMI (beta = 0.190; p < 0.01) are positively correlated with pouch size.

CONCLUSION

The analysis demonstrates that initial gastric pouch size is not the only significant component for successful weight loss after LRYGB. Male gender and increased preoperative BMI were identified as factors predicting pouch size. Efforts to standardize small pouch size for all patients seems important to the success of surgical therapy for morbid obesity.

Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit

OBJECTIVES

To determine the incidence and nature of adverse events and delay to patient transfer from emergency department to intensive care unit (ICU) in a metropolitan tertiary hospital.

METHOD

A 6-month prospective observational study in conjunction with a retrospective chart audit on all emergency department patients admitted to ICU, including those admitted via theatre or after a computed tomography scan.

RESULTS

Equipment problems was the most common adverse event occurring in 9% of patient transfers (n = 290). Hypothermia events occurred in 7% of transfers, cardiovascular events in 6% of patient transfers, delays to transfer >20 min occurred in 38% of the prospectively audited cases, with 14% waiting >1 h. One patient was found to have an incorrect patient identification band during a preoperative check.

CONCLUSIONS

This study generally reported lower rates of adverse events than noted in previous studies involving critically ill transfers. The most significant finding was the application of an incorrect patient identification band and has prompted a review of practice. The establishment of benchmark indicators for adverse events and delays in transfer will be useful for future audits.

Study of the effects of once daily doses of trilostane on cortisol concentrations and responsiveness to adrenocorticotrophic hormone in hyperadrenocorticoid dogs

The effects of trilostane, a 3beta-hydroxysteroid dehydrogenase inhibitor on basal cortisol concentrations and the results of ACTH stimulation tests in dogs with pituitary-dependent hyperadrenocorticism were investigated. In eight of nine dogs trilostane suppressed the concentration of cortisol below the lower limit of the reference range (<50 nmol/l) for a mean (sd) of 3.5 (2.3) hours during the day, but for no longer than 13 hours. In another 10 dogs, there was a clear difference between the post ACTH cortisol concentrations observed four and 24 hours after the administration of trilostane. Furthermore, in the six dogs whose clinical signs were poorly controlled the post-ACTH concentrations observed four and 24 hours after the administration of trilostane were always higher than the equivalent cortisol concentrations in the four dogs whose clinical signs were controlled. A short duration of drug action may be responsible for the failure of some dogs to respond adequately to once daily trilostane administration.

Multifocality and multifocal postradiation sarcomas

Hypothetically, any site in a radiation portal has potential for late malignant transformation. Secondary malignant neoplasms may occur after almost any index cancer has been treated with radiation and/or chemotherapy. The incidence of secondary malignant neoplasms, histopathology, time delay, radiation dose, cytotoxic agents, age and type of initial malignancy, and outcome all negatively impact cancer survivors. We highlight the new concept of multifocality, defined as greater than two noncontiguous second malignant neoplasms that develop in a prior radiation port. We identified 48 patients with postradiation sarcomas from three prospectively collected databases. Fifteen of these patients (31%) had evidence of multifocal postradiation sarcomas. Five of 10 women had multifocal postradiation sarcomas after breast-conserving surgery for carcinoma. The longer the time interval between the index cancer and post-radiation sarcoma, the greater the likelihood of multifocal malignant transformation occurring.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Dynamic tracheal collapse associated with disseminated histiocytic sarcoma in a cat

This case report describes an unusual presentation of histiocytic sarcoma in a domestic shorthair cat. Initial investigation revealed a haemodynamically insignificant hypertrophic cardiomyopathy, bronchitis and a mild irregularity of the cervical trachea. The cat's disease progressed over a two-week period. Repeat radiography and tracheoscopy revealed a marked dynamic tracheal collapse associated with a raised plaque-like lesion within the cervical trachea. Subsequent post-mortem examination and histopathology revealed disseminated histiocytic sarcoma involving the trachea and kidneys. This is the first reported case of a histiocytic sarcoma involving the trachea in either dogs or cats.

A phase II study of paclitaxel and vinorelbine (Pacl-Vin) in hormone-refractory metastatic prostate cancer (HRPC): Double tubulin targeting

14559

Background: Phase 2 trials of Paclitaxel+corticosteroid or Vinorelbine+corticosteroid have shown 20–40% PSA responses. Preclinical models have shown synergy between Paclitaxel and Vinorelbine. A phase I trial showed this to be a tolerable combination. Methods: The aim of this study was to determine the efficacy and safety of Paclitaxel and Vinorelbine. 30 castrate pts with progressive, metastatic prostate cancer were enrolled. Previous radiotherapy, strontium therapy, 1 line of chemotherapy, and concurrent bisphosphonate therapy were allowed. Pts were treated with Paclitaxel 40 mg/m2 (1 hr), and Vinorelbine 20 mg/m2 iv on day-1 & day-8 of a 21-day cycle. All pts received standard premedication for Paclitaxel including dexamethasone. Results: Baseline pt characteristics were: median ECOG PS of 1 (range 0–2), median age 71, mean PSA 413ng/mL, mean Hb 11.9 g/dL. For 10 pts with measurable disease the partial response rate was 20%, with 70% of pts achieving stable disease (SD). Of 23 assessable pts, 9% had 50% decline in PSA, and 78% had SD, maintained for at least 4 weeks. Median overall survival was 7.3 months. Median progression free survival was 3.3 months. All pts completed quality of life (QOL) questionnaires. There was an improvement over baseline after 3 cycles of therapy in pts pain, appetite, constipation, voiding and overall wellbeing (p = non-significant). Grade 3/4 toxicities were: anemia 3%, neutropenia 8%, infection 2%, febrile neutropenia 4%, lethargy 1%, and somnolescence 1%. 1 pt died as a result of sepsis and neutropenia. Conclusions: In this poor prognostic cohort of pts the combination of Paclitaxel and Vinorelbine is a tolerable regimen, which has demonstrated minor PSA response, with the majority of pts achieving PSA stability. There was some objective response to this regimen and importantly it stabilized disease in a majority of pts. Important QOL parameters such as pain were improved.This is a useful regimen to test in poor prognosis HRPC pts.

No significant financial relationships to disclose.

Milroy disease and the VEGFR-3 mutation phenotype

Primary congenital lymphoedema (Milroy disease) is a rare autosomal dominant condition for which a major causative gene defect has recently been determined. Mutations in the vascular endothelial growth factor receptor 3 (VEGFR-3) gene have now been described in 13 families world-wide. This is a review of the condition based on the clinical findings in 71 subjects from 10 families. All 71 individuals have a mutation in VEGFR-3. Ninety per cent of the 71 individuals carrying a VEGFR-3 mutation showed signs of oedema, which was confined in all cases to the lower limbs. In all but two cases onset of swelling was from birth. Other symptoms and signs included cellulitis (20%), large calibre leg veins (23%), papillomatosis (10%), and upslanting toenails (10%). In males, hydrocoele was the next most common finding after oedema (37%). Thorough clinical examination of these patients indicates that there are few clinical signs in addition to lower limb oedema. Rigorous phenotyping of patients produces a high yield of VEGFR-3 mutations.

Impacts of participating in confidential enquiry panels: a qualitative study

OBJECTIVE

To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy.

DESIGN

Qualitative interview study.

SETTING

The former northern health region of England.

SAMPLE

Eighteen health professionals who had participated in at least one confidential enquiry panel.

METHODS

Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST.

MAIN OUTCOME MEASURES

Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries.

RESULTS

Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported.

CONCLUSIONS

The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.

Cyclin D1 and p21 is elevated in the giant cells of giant cell tumors

Alterations of cell cycle regulatory proteins, especially those that regulate G1 to S transition, have been implicated in the pathogenesis of a wide variety of human tumors. In previous studies we showed that that there is overexpression of cyclin D1 protein predominately in the giant cell component of giant cell tumors of bone. The purpose of this study was to investigate the mechanisms that may be responsible for cyclin D1 accumulation in giant cell tumors. Giant cell tumors have high levels of cyclin D1 mRNA and the giant cell-enriched population of these tumors have significantly more mRNA and protein expression of cyclin D1 than the mononuclear cell population. The giant cells also expressed higher levels of p21 protein and more p21 bound to cyclin D1 than the mononuclear cells. It is possible that p21 may be contributing to the cyclin D1 accumulation that occurs in the giant cells and perhaps even giant cell formation in these tumors. Additional studies are required to confirm the role of p21 in the pathogenesis of these tumors.

A Study of the Stick-Slip Motion of Machine Tool Feed Drives

The phenomenon of ‘stick-slip’ oscillations of the feed drives of machine tools is an important problem in the design of certain types of machine tools. The factors contributing to this particular type of instability are studied both experimentally and analytically with the aid of a simple model based on dynamic measurements. The experimental work is restricted to a scraped cast iron-cup ground cast iron slideway interface. The principal experimental variables are lubricant viscosity and the natural frequency of the drive. The dynamic observations provide evidence and data that enable the use of a simple model rather than the more usual application of an involved analysis. The consideration of analytical and experimental results allows further understanding of the mechanism of feed drive instability to be developed.

Testosterone for peri- and postmenopausal women

BACKGROUND

: The value of adding testosterone to hormone therapy (HT) for the management of peri- and postmenopausal women is controversial and has not been systematically reviewed.

OBJECTIVES

: To determine the benefits and risks of testosterone therapy for peri- and postmenopausal women taking hormone therapy.

SEARCH STRATEGY

: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (1st November 2003), The Cochrane Library (Issue 2, 2003), MEDLINE (1966 to 1st November 2003), EMBASE (1980 to 1st November 2003), Biological Abstracts (1969 to 2002), PsycINFO (1972 to 1st November 2003), CINAHL (1982 to 1st November 2003), and reference lists of articles. We also contacted pharmaceutical companies and researchers in the field.

SELECTION CRITERIA

: Studies that were randomized comparisons of testosterone plus hormone therapy versus hormone therapy alone in peri- or postmenopausal women.

DATA COLLECTION AND ANALYSIS

: Two review authors assessed the quality of the trials and extracted data independently. Where it was necessary, the corresponding authors of eligible trials were contacted for additional information. For dichotomous outcomes Peto odds ratios and 95% confidence intervals were calculated. For continuous outcomes non-skewed data from valid scales were synthesized using a weighted mean difference or standardized mean difference. If statistical heterogeneity was found, a random-effects model was used and reasons for the heterogeneity were explored and discussed.

MAIN RESULTS

: Twenty-three trials with 1957 participants were included in the review. The median study duration was 6 months (range 1.5 to 24 months). Most of the trials were of adequate quality with regard to randomization and concealment of allocation sequence. The major methodological limitations were attrition bias and lack of a washout period in the cross-over studies. The pooled estimate from the studies suggested that the addition of testosterone to HT regimens improved sexual function scores for postmenopausal women. A significant adverse effect was a decrease in high-density lipoprotein (HDL) cholesterol levels. The discontinuation rate was not significantly greater with testosterone therapy (Peto odds ratio 1.01, 95% confidence interval 0.76 to 1.33) than with HT alone. There was insufficient evidence of a treatment effect for perimenopausal women or for other outcomes.

AUTHORS' CONCLUSIONS

: Only a limited number of studies could be pooled in the meta-analyses. This limited the power of the meta-analysis to provide conclusions about efficacy and safety. However, there is evidence that adding testosterone to HT has a beneficial effect on sexual function in postmenopausal women. There was a reduction in HDL cholesterol associated with the addition of testosterone to the HT regimens. The meta-analysis combined studies using different testosterone regimens. It is, therefore, difficult to estimate the effect of testosterone on sexual function in association with any individual hormone treatment regimen.

Androgen levels in adult females: changes with age, menopause, and oophorectomy

CONTEXT

Changes in androgen levels across the adult female life span and the effects of natural menopause and oophorectomy have not been clearly established.

OBJECTIVE

The objective of this study was to document the effects of age on androgen levels in healthy women and to explore the effects of natural and surgical menopause.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted of 1423 non-healthcare-seeking women, aged 18-75 yr, randomly recruited from the community over 15 months.

MAIN OUTCOME MEASURES

Serum levels by age of total testosterone (T), calculated free T, dehydroepiandrosterone sulfate, and androstenedione in a reference group of women free of confounding factors. Women in the reference group had no usage of exogenous steroid therapy; no history of tubal ligation, hysterectomy, or bilateral oophorectomy; and no hyperprolactinemia or polycystic ovarian syndrome. The effects of natural and surgical menopause on sex steroid levels were also examined.

RESULTS

In the reference population (n = 595), total T, calculated free T, dehydroepiandrosterone sulfate, and androstenedione declined steeply with age (P < 0.001), with the decline of each being greater in the earlier than the later decades. Examination of serum androgen levels by year in women aged 45-54 yr showed no independent effect of menopausal status on androgen levels. In women aged 55 yr or older, those who reported bilateral oophorectomy and were not on exogenous steroids had significantly lower total T and free T levels than women 55 yr or older in the reference group.

CONCLUSIONS

We report that serum androgen levels decline steeply in the early reproductive years and do not vary because a consequence of natural menopause and that the postmenopausal ovary appears to be an ongoing site of testosterone production. These significant variations in androgens with age must be taken into account when normal ranges are reported and in studies of the role of androgens in women.

Treatment of insulinoma in a springer spaniel with streptozotocin

An eight-year-old, female springer spaniel was treated for metastatic insulinoma with a single intravenous dose of 500 mg/m2 streptozotocin (SZN), and pre- and post-treatment diuresis. A tapering dose of corticosteroids was also administered over a 28 day period. SZN and corticosteroid administration resulted in resolution of hypoglycaemia and subsequent development of diabetes mellitus. Further metastases caused cervical spinal pain and the dog was euthanased 118 days after SZN administration. SZN can be safely used for the treatment of canine insulinoma, but, when compared with other published cases, a marked variation in clinical response to this drug exists and further study is warranted.